Method for coupling soft tissue to a bone

ABSTRACT

A method for coupling tissue with a flexible member including a tail and a self-locking construct coupled to the tail. The self-locking construct includes an adjustable first loop and an adjustable second loop coupled thereto. The method includes implanting an anchor in bone, the anchor slidably mounted to the tail. The tail is positioned relative to the tissue. An end of the tail is inserted through the first loop. The tail is passed through the first loop, the second loop is pulled into the anchor, and the self-locking construct is positioned relative to the tissue. The self-locking construct is tightened against the tissue by pulling on an end of the self-locking construct. The first loop is tightened onto the second loop.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent application Ser. Nos. 13/757,003 and 13/757,019, each of which were filed on Feb. 1, 2013, and each of which are continuation-in-part applications of U.S. patent application Ser. No. 13/293,825, filed on Nov. 10, 2011. The entire disclosures of these applications are incorporated herein by reference.

FIELD

The present disclosure relates to apparatuses for coupling a first tissue to a second tissue, such as coupling soft tissue to bone and methods for coupling two portions of soft tissue together.

BACKGROUND

This section provides background information related to the present disclosure, which is not necessarily prior art.

Arthroscopic procedures often include sutures and anchors to secure soft tissue to bone, and to secure separated portions of soft tissue together. Despite their widespread use, sutures and suture anchors, as well as methods for their use, can be improved. For example, tying sutures into knots may be very time consuming and difficult to perform, particularly inside the joint space. As a result, the cost of the procedure may be increased and the capacity of the surgeon may be limited. Furthermore, the strength of the repair may be limited by the strength of the knot. The methods and apparatuses disclosed herein address these issues and numerous others.

SUMMARY

This section provides a general summary of the disclosure, and is not a comprehensive disclosure of its full scope or all of its features.

The present teachings provide for a method for coupling tissue with a flexible member including a tail and a self-locking construct coupled to the tail. The self-locking construct includes an adjustable first loop and an adjustable second loop coupled thereto. The method includes implanting an anchor in bone, the anchor slidably mounted to the tail. The tail is positioned relative to the tissue. An end of the tail is inserted through the first loop. The tail is passed through the first loop, the second loop is pulled into the anchor, and the self-locking construct is positioned relative to the tissue. The self-locking construct is tightened against the tissue by pulling on an end of the self-locking construct. The first loop is tightened onto the second loop.

The present teaching further provide for a method for coupling tissue with a flexible member including a tail and a self-locking construct coupled to the tail, the self-locking construct including an adjustable first loop and an adjustable second loop coupled thereto. The method includes the following: implanting an anchor in bone, the anchor slidably mounted to the tail and supported at a distal end of a rod extending from a handle of an insertion tool; decoupling a retention member from the handle to release the tail from being retained between the handle and the retention member; passing the tail through a flexible loop mounted to the retention member, the flexible loop extending out from within a plunger of the retention member, the plunger extending through the first loop, the first loop coupled to a support flange of the retention member; pushing the first loop off the support flange by actuating the plunger; moving the first loop onto the tail; pulling the tail through the first loop; and tightening the self-locking construct against the tissue by pulling on an end of the self-locking construct.

The present teachings also provide for a method for coupling tissue with a flexible member including a tail and a self-locking construct coupled to the tail, the self-locking construct including an adjustable first loop and an adjustable second loop coupled thereto. The method includes implanting an anchor in bone, the anchor slidably mounted to the tail and supported at a distal end of a rod extending from a handle of an insertion tool; decoupling a retention member from the handle to release the tail from being retained between the handle and the retention member; passing the tail through a flexible loop mounted to the retention member, the flexible loop extending out from within a plunger of the retention member, the plunger extending through the first loop, the first loop coupled to a support flange of the retention member; pushing the first loop off the support flange by actuating the plunger; moving the first loop onto the tail; pulling the tail through the first loop; and tightening the self-locking construct against the tissue by pulling on an end of the self-locking construct.

Further areas of applicability will become apparent from the description provided herein. The description and specific examples in this summary are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustrative purposes only of selected embodiments and not all possible implementations, and are not intended to limit the scope of the present disclosure.

FIG. 1A illustrates a knotless suture anchor device according to the present teachings;

FIG. 1B is a close-up view of a suture construct of the knotless suture anchor device of FIG. 1A;

FIG. 1C illustrates another knotless suture anchor device according to the present teachings;

FIG. 2 illustrates the knotless suture anchor device of FIG. 1A implanted in bone;

FIG. 3 illustrates a suture tail of the knotless suture anchor device of FIG. 1A passed around tissue;

FIG. 4 illustrates the suture tail being passed through a first suture loop of the suture construct of the knotless suture anchor device of FIG. 1A;

FIG. 5 illustrates the suture construct after it has been pulled through a soft anchor of the knotless suture anchor device of FIG. 1 to surround the tissue;

FIG. 6 illustrates the suture construct tightened around the tissue;

FIG. 7A illustrates the knotless suture anchor device of FIG. 1A implanted in bone and including a second soft anchor, the device implanted through tissue to secure the tissue to bone;

FIG. 7B illustrates the suture tail being passed through the first suture loop;

FIG. 7C illustrates the suture construct tightened against the tissue to secure the tissue to bone;

FIGS. 8A-8D illustrate another method for coupling tissue to bone using the knotless suture anchor device of FIG. 1A;

FIG. 9 illustrates an additional arrangement of the knotless suture anchor device of FIG. 1A for coupling tissue to bone;

FIG. 10 illustrates yet another arrangement of the knotless suture anchor device of FIG. 1A for coupling tissue to bone;

FIGS. 11A-11E illustrate yet another method for coupling tissue to bone using the knotless suture anchor device of FIG. 1A;

FIG. 12 illustrates a further arrangement of the knotless suture anchor device of FIG. 1A for coupling tissue to bone;

FIGS. 13A-13D illustrate a method for coupling two separated tissue portions using the knotless suture anchor device of FIG. 1A;

FIG. 14 is a perspective view of an insertion device according to the present teachings;

FIG. 15 is a perspective view of a handle and a suture retention assembly of the insertion device of FIG. 14 ;

FIG. 16 is a cross-sectional view of the handle of the insertion device of FIG. 14 taken along line 16-16 of FIG. 14 ;

FIG. 17A is a cross-sectional view taken along line 17A-17A of FIG. 14 of the suture retention assembly of the insertion device of FIG. 14 in a first position;

FIG. 17B is a cross-sectional view of the suture retention assembly in a second position;

FIGS. 18-23 illustrate a method of using the insertion device of FIG. 14 to secure tissue to bone with the knotless suture anchor device;

FIG. 24 is a perspective view of another suture retention assembly for the insertion device of FIG. 14 ;

FIG. 25 is a perspective view of another insertion device according to the present teachings;

FIG. 26 is a perspective view of a handle of the insertion tool of FIG. 25 ;

FIG. 27 is side view of the handle of the insertion tool of FIG. 25 ;

FIG. 28 is a perspective view of another insertion device according to the present teachings;

FIG. 29 is a perspective view of a handle of the insertion device of FIG. 28 ;

FIG. 30 is another perspective view of the handle of the insertion device of FIG. 28 ;

FIG. 31 is a perspective view of the handle of the insertion device of FIG. 28 showing a pin being withdrawn from the handle;

FIG. 32 illustrates the suture tail being passed through the first suture loop of the suture construct with the pin of FIG. 31 ;

FIGS. 33-38 illustrate a method of repairing torn labrum tissue using the knotless suture anchor device of FIG. 1 ;

FIG. 39 is a perspective view of another insertion device according to the present teachings;

FIG. 40 is an exploded view of the insertion device of FIG. 39 ;

FIG. 41 is a perspective view of the insertion device of FIG. 39 with a suture retention assembly separated from a handle of the insertion device;

FIG. 42 is a perspective view of the suture retention assembly with a suture construct mounted thereto;

FIGS. 43 and 44 illustrate passage of a tail of the suture construct through a loop of the suture construct using the suture retention assembly;

FIGS. 45-53 illustrate formation of a tail of a knotless suture anchor device according to the present teachings; and

FIGS. 54-61 illustrate formation of a suture construct of a knotless suture anchor according to the present teachings, and coupling of the suture construct to the tail.

Corresponding reference numerals indicate corresponding parts throughout the several views of the drawings.

DETAILED DESCRIPTION

Example embodiments will now be described more fully with reference to the accompanying drawings.

With initial reference to FIG. 1A, a knotless suture anchor device, or assembly, or system is generally illustrated at reference numeral 10. The device generally includes a suture tail 12 and a suture construct 14 connected thereto. The suture tail 12 and the suture construct 14 can be made of any suitable flexible material or member, and need not be made of a suture. The suture tail 12 and the suture construct 14 can be made of the same or different materials. When the suture tail 12 and/or the suture construct 14 are made of sutures, any suitable suture can be used. For example, a braided hollow-core suture can be used. The braided suture can include a first end and a second end with an outer wall that defines a passage therethrough. Any suitable braided suture can be used, such as any of the braided sutures disclosed in U.S. patent application Ser. No. 12/915,962 ('962 Application) titled Method and Apparatus for Securing Soft Tissue to Bone, which was filed on Oct. 29, 2010, published as Publication No. 2011/0098727 on Apr. 28, 2011, and is assigned to Biomet Sports Medicine, LLC. The disclosure of the '962 application is incorporated herein by reference. To help distinguish between the suture tail 12 and the suture construct 14, which can be particularly helpful for a surgeon during surgery, the suture tail 12 and the suture construct 14 can be provide with different colors or designs, for example.

The suture tail 12 generally includes a first end 16 and a second end 18, which is opposite to the first end 16. The suture tail 12 can be any suitable length, such as about 30 inches. The suture tail 12 defines a suture tail sleeve portion 20 proximate to the second end 18 of the suture tail 12. While the suture tail sleeve portion 20 is illustrated as being proximate to the second end 18, it may alternatively be proximate to the first end 16 or at any suitable position therebetween. The suture tail sleeve portion 20 defines an elongated passageway 22 extending along at least a portion of the suture tail 12. If the suture tail 12 is a braided hollow-core suture, the passageway 22 can extend from the first end 16 to the second end 18 of the suture tail 12. The passageway 22 exits through an outer wall of the suture tail 12 at a first opening 24 and a second opening 26 at opposite ends of the passageway 22. The second opening 26 is closer to the second end 18 of the suture tail 12 than the first opening 24 is. The second opening 26 is spaced apart from the second end 18. The suture construct 14 extends through the suture tail sleeve portion 20 to connect the suture construct 14 to the suture tail 12. The portion of the suture tail 12 defining the suture tail sleeve portion 20 and the portions of the suture tail 12 proximate to either end thereof define a locking member or portion 28 of the suture tail 12, as further described herein.

The suture tail 12 can include a soft or flexible anchor 30 at any suitable position between the first end 16 and the second end 18, such as about halfway between the first end 16 and the second end 18. The anchor 30 can be an elongate member having a sleeve or tubular configuration with a first anchor end 32 and a second anchor end 34 at opposite ends thereof. An internal passage 40 is defined by a wall of the anchor 30 and extends between the first anchor end 32 and the second anchor end 34. The anchor 30 can be made of resorbable or non-resorbable materials, including braided suture, sponges and sponge-like materials, including braided suture, sponges and sponge-like materials in solid form, perforated materials, woven/braided from biocompatible materials or fibers, such as, for example, polymer, polyester, polyethylene, cotton, silk, or other natural or synthetic materials.

The anchor 30 can have any properties that allow the anchor 30 to change shape. In this regard, the anchor 30 can be, for example, complaint, flexible, foldable, squashable, squeezable, deformable, limp, flaccid, elastic, low-modulus, soft, spongy or perforated, or have any other characteristic property that allows it to change shape. In some aspects, the anchor 30 can be coated with biological or biocompatible coatings and also can be soaked in platelets and other biologics, which can be easily absorbed by the flexible anchor 30. In an exemplary configuration, the anchor 30 can be formed from a strand of No. 5 braided polyester suture. In other words, multiple fibers can be braided together to form a hollow braided suture having a longitudinal passage.

The anchor 30 includes a first opening 36 and a second opening 38 defined in the wall of the anchor 30. The first opening 36 is proximate to, but spaced apart from, the first anchor end 32. The second opening 38 is proximate to, but spaced apart from, the second anchor end 34. The suture tail 12 can be can be passed through the second opening 38, guided into and along the internal passage 40, and passed out of the internal passage 40 through the first opening 36. The first and the second openings 36 and 38 can be apertures or voids in the woven fabric of the anchor 30, such that the first and the second openings 36 and 38 do not disrupt or break the weave of the anchor 30 between the first and the second anchor ends 32 and 34 and the corresponding first and second openings 36 and 38 can define anchoring leg or tail portions 42 that can provide additional resistance for securing the anchor 30 relative to the bone.

In one exemplary configuration, the suture tail 12 can pass only through the first and second openings 36 and 38 and a portion of the internal passage 40 extending therebetween to form a loop that does not extend through the first or the second anchor ends 32 and 34. In another exemplary configuration, the suture tail 12 can extend into the second anchor end 34, through the internal passage 40, and out the first anchor end 32. In such a configuration, the anchor 30 need not include the first opening 36 or the second opening 38. This configuration is described in U.S. application Ser. No. 13/485,304 filed May 31, 2012 and assigned to Biomet Sports Medicine, LLC of Warsaw, Ind., which is incorporated herein by reference and referred to herein as the '304 Application. The anchor 30 can be any of the anchors disclosed in the '304 Application. For example, the anchors of FIGS. 20 and 21 of the '304 Application can be used when it is desirable to add additional flexible anchors

In addition to the anchor 30, one or more additional anchors, identical to or substantially similar to the anchor 30, can be mounted to the suture tail 12. The device 10 can be provided with additional anchors mounted to the suture tail 12, and/or additional anchors can be added to the suture tail 12 during the surgical procedure. For example, a health care professional can add additional anchors to the suture tail 12. The additional anchors can be added in any suitable manner, such as by using any one of the anchor reload devices disclosed in the '304 Application.

While FIG. 1A illustrates a single suture tail 12 connected to the anchor 30, one or more suture tails 12 each with a separate suture construct 14 can be connected to the anchor 30. The additional suture tail(s) 12 can extend through the internal passage 40 or through an additional anchor sleeve defined by the first anchor 30. For example and as illustrated in FIG. 1C, a second suture tail 12A can be seated in the internal passage 40 and thereby connected to the anchor 30. Connected to the second suture tail 12A is a second suture construct 14A. The second suture tail 12A and the second suture construct 14A can be substantially similar to, or identical to, the suture tail 12 and the suture construct 14 respectively. The suture tail 12 and the suture construct 14 can thus be a first suture tail 12 and a first suture construct 14.

The suture construct 14 is a self-locking suture construct including a braided suture. The suture construct generally includes a first adjustable suture loop 50, a second adjustable suture loop 52, a first suture construct body 54, and a second suture construct body 56. The first adjustable suture loop 50 can be non-adjustable as well. A first end 58 of the suture construct 14 is opposite to a second end 60 of the suture construct 14. With particular reference to FIG. 1B, the first body 54 defines a first passage portion 62. The second body 56 defines a second passage portion 64. The first passage portion 62 defines a first pair of apertures 80 a and 80 b at opposite ends thereof through a wall of suture construct 14. The second passage portion 64 defines a second pair of apertures 82 a and 82 b at opposite ends thereof through the wall of the suture construct 14. While the first and the second passage portions 62 and 64 each have two openings 80 a/80 b and 82 a/82 b respectively, the first and the second passage portions 62 and 64 can have additional openings and/or can include additional passage portions.

The first body 54 is formed proximate to the first end 58 of the suture construct 14. A portion of the suture construct 14 between the second body 56 and the first end 58 is passed through the first pair of apertures 80 a and 80 b of the first passage portion 62 to define the first adjustable suture loop or noose 50. The size of the first adjustable suture loop 50 can be adjusted by sliding the first end 58 of the suture construct 14 along the first adjustable suture loop 50. For example, the first adjustable suture loop 50 can be closed (made smaller) by sliding the first end away from the second body 56.

Tension in the first adjustable suture loop 50 can cause the first body 54 defining the first passage portion 62 to be placed in tension and therefore cause first passage portion 62 to constrict about portion 84 passed therethrough. This constriction reduces the diameter of the first passage portion 62, thus forming a mechanical interface between exterior surfaces of portion 84 and an interior surface of the first passage portion 62. This constriction results in static friction between the interior and exterior surfaces at the mechanical interface, causing the first adjustable suture loop 50 to “automatically” lock in a reduced size or diameter configuration in which tension is maintained without use of a knot. This can be used to secure the first adjustable suture loop 50 to the second adjustable suture loop 52, as described herein.

The second end 60 of the suture construct 14 is passed through the first and the second openings 82 a and 82 b of the second passage portion 64 to define the second adjustable suture loop 52. The size of the second adjustable suture loop 52 can be adjusted by moving the second end 60 of the suture construct 14. For example, the second adjustable suture loop 52 can be closed (made smaller) by pulling on the second end 60. A portion of the suture construct 14 defining the second adjustable suture loop 52 extends through the suture tail sleeve portion 20, and is slidably received in the suture tail sleeve portion 20 to connect the suture construct 14 to the suture tail 12.

The pulling or tensioning of the first end 16 of the suture tail 12 can cause reciprocal movement of portion 86 relative to the second passage portion 64 and the second adjustable suture loop 52 can be reduced to a desired size and placed in a desired tension. Tension in the second adjustable suture loop 52 can cause the second body 56 defining the second passage portion 64 to be placed in tension and therefore cause second passage portion 64 to constrict about portion 86 passed therethrough. This constriction reduces the diameter of the second passage portion 64, thus forming a mechanical interface between exterior surfaces of portion 86 and an interior surface of the second passage portion 64. This constriction results in static friction between the interior and exterior surfaces at the mechanical interface, causing the second adjustable suture loop 52 to “automatically” lock in a reduced size or diameter configuration in which tension is maintained without use of a knot. This can be used to secure a labral tear, a rotator cuff tear, and/or in any other suitable procedure. Any other suitable self-locking suture construct configuration can be included as well, such as any of those disclosed in the '962 Application.

With additional reference to FIG. 2 , a method for implanting the knotless suture anchor device 10 in a bone 102 to secure a tissue 104 to the bone 102 will now be described. As illustrated, the bone 102 includes a hard, outer cortical bone layer 106 and a softer, inner cancellous bone layer 108. The bone 102 and tissue 104 can be any suitable bone and tissue. For example and as further described herein, the knotless suture anchor device 10 can be used to secure a torn rotator cuff or labrum in place.

As illustrated in FIG. 2 , a bone hole 110 is formed in the bone 102 using any suitable device, such as a surgical drill. The bone hole 110 is formed proximate to the tissue 104 to be secured to the bone 102. The anchor 30 is inserted into the bone hole 110 and positioned such that the first anchor end 32 and the second anchor end 34 abut an undersurface 112 of the cortical bone layer 106 at opposite sides of the bone hole 110, which restricts the suture tail 12 from being pulled out from within the bone 102. The anchor 30 can be inserted using any suitable inserter, such as those described herein. The '962 Application, which is incorporated by reference, provides additional disclosure for forming a bone hole and implanting a flexible anchor. The additional disclosure of the '962 Application also applies to the forming of bone hole 110 and insertion of anchor 30 within the bone hole 110.

With additional reference to FIG. 3 , the first end 16 of the suture tail 12 is passed around and/or through the tissue 104 such that the tissue 104 is between a first portion 66 and a second portion 68 of the suture tail 12. The first portion 66 is between the first end 16 and the anchor 30. The second portion 68 is between the second end 18 and the anchor 30.

With additional reference to FIGS. 4 and 5 , the first end 16 of the suture tail 12 is inserted through the first adjustable suture loop 50. The entire suture tail 12 is pulled through the first adjustable suture loop 50 and the entire suture tail 12 is pulled through the internal passage 40. Pulling the entire suture tail 12 through the internal passage 40 causes the suture construct 14 to be pulled into the internal passage 40 such that the second adjustable suture loop 52 extends through the internal passage 40. The internal passage 40 is thus dimensioned large enough to permit passage of both the suture tail 12 and the second adjustable suture loop 52. As illustrated in FIG. 5 , the tissue 104 is encompassed entirely by the suture construct 14 and the second adjustable suture loop 52 extends through the first adjustable suture loop 50. The internal passage 40 is also dimensioned large enough to permit slidable adjustment of the suture construct 14 through the internal passage 40.

With continued reference to FIG. 5 and additional reference to FIG. 6 , the second end 60 of the suture construct 14 is pulled to tighten the suture construct 14 around the tissue 104 and retain the tissue 104 against the bone 102 at any suitable tension. As described above, the second adjustable suture loop is self-locking, and thereby secures the tissue 101 without the need for tying a knot. To further secure the suture construct 14 around the tissue 104, the first end 58 of the suture construct 14 is slid away from the second body 56, which closes and tightens the first adjustable suture loop 50 onto the second adjustable suture loop 52 and provides further control over tension applied to the tissue 104. Further pulling of the second end 60 of the suture construct 14 draws the locking member 28 of the suture tail 12 against the first adjustable suture loop 50 to provide the locking member 28 with the locked configuration illustrated in FIG. 6 . The first adjustable suture loop 50 and the second adjustable suture loop 52 surround the tissue 104, thereby defining a suture capture region of the device 10. As described above, the first adjustable suture loop is self-locking. Thus, the first adjustable suture loop 50 can be locked onto the second adjustable suture loop 52 without the need to tie a knot.

In the locked configuration of FIG. 6 , the portions of the suture tail 12 defining the first opening 24 and the second opening 26 are drawn together, thereby causing the suture tail 12 to assume the locked configuration of FIG. 6 , in which the locking member 28 has a generally horseshoe-shaped, u-shaped, or bunched, configuration. In the locked configuration of FIG. 6 , the locking member 28 restricts the suture tail 12 from passing back through the first adjustable suture loop 50, which prevents the suture construct 14 from loosening its hold of the tissue 104 against the bone 102.

As illustrated in FIG. 6 , upon tensioning the second adjustable suture loop 52 onto the tissue 104, the anchor 30 is forced upward against the undersurface 112 of the bone 102. This force causes the anchor 30 to deform to the collapsed, balled, or squished position of FIG. 6 , which further retains the anchor 30 within the bone. Although the other figures herein do not specifically illustrate the anchor 30 within this configuration, further tensioning of the second adjustable suture loop 52 such that the anchor 30 is forced against the undersurface 112 of the bone 102 will cause the anchors 30 to assume the position of FIG. 6 .

With continued reference to FIG. 6 , excess portion 88 of the suture construct 14 pulled through the second body 56 at the second end 60 of the suture construct 14 can be cut and removed. The excess portion 90 of the suture tail 12 beyond the locking member 28 can be cut and removed as well. While the method for securing the tissue 104 to the bone 102 described above includes implanting the anchor 30 within the bone 102 before passing the suture tail 12 around the tissue 104, the suture tail 12 can be passed around the tissue before the anchor 30 is implanted in the bone 102.

With additional reference to FIGS. 7A and 7B, use of the knotless suture anchor device 10 to secure a separated rotator cuff tissue 120 to a humerus 122 is illustrated. As illustrated, the device 10 includes a second anchor 70 attached to the suture tail 12 in addition to the anchor 30, which is also referred to herein as a first anchor 30. The second anchor 70 is substantially identical to, or the same as, the first anchor 30. The second anchor 70 can be attached to the suture tail 12 in any suitable manner, such as by using the suture anchor reload assembly disclosed in FIGS. 17-21 of the '304 Application, which is incorporated herein by reference as set forth above. The second anchor 70 is attached to the suture tail 12 between the first end 16 of the suture tail 12 and the first anchor 30. The knotless suture anchor device 10 can be used to fasten any suitable portion of the tissue 120 to the humerus 122. For example, the device 10 can be arranged to extend in the medial to lateral direction, or to extend in the anterior to posterior direction.

With particular reference to FIG. 7A, the first anchor 30 is first implanted in a first bone hole 124A formed in the humerus 122 and arranged such that the first anchor 30 is secured within a cancellous bone layer 126 due to contact with an undersurface 128 of cortical bone layer 130. The first anchor 30 can be implanted in any suitable manner, such as by using the inserter 150 the '304 Application, or any of the inserters described herein. The first anchor 30 is inserted through the rotator cuff tissue 120 such that both the first portion 66 of the suture tail 12 and the second portion 68 of the suture tail 12 extend through the rotator cuff tissue 120.

The second anchor 70 can be implanted in the humerus 122 in a second bone hole 124B in the same way that the first anchor 30 is implanted, such as by using the inserter disclosed in the '304 Application or any of the inserters described herein. The second anchor 70 is implanted through the tissue 120, and thus the suture tail 12 extends through the tissue 120. Thus, as illustrated in FIG. 7A, the suture tail 12 extends through the tissue 120 twice at the first anchor 30 (first in through the tissue 120 to the first anchor 30 and then back out through the tissue 120 from the first anchor 30) and twice at the second anchor 70 (first in through the tissue 120 to the second anchor 70 and then back out through the tissue 120 from the second anchor 70).

With additional reference to FIG. 7B, the rotator cuff tissue 120 is tightened against the humerus 122 and secured thereto by inserting the first end 16 of the suture tail 12 through the first adjustable suture loop 50 of the suture construct 14, and pulling the suture tail 12 completely through the first and the second anchors 30 and 70, similar to that which is illustrated in FIGS. 4 and 5 . As a result, the suture construct 14 is carried through and extends through both the first anchor 30 and the second anchor 70, as illustrated in FIG. 7C.

With continued reference to FIG. 7C, the first adjustable suture loop 50 is coupled to the second adjustable suture loop 52 at an outer surface 132 of the tissue 120. Pulling the second end 60 of the suture construct 14 tightens the suture construct 14 against the tissue 120 to hold an inner surface 134 of the tissue 120 against the humerus 122. Pulling the second end 60 also allows a surgeon to tension the tissue 120 against the humerus 122. In this arrangement, the suture construct 14 is thus implanted such that it overlaps the outer surface 132 of tissue 120 between the first anchor 30 and the second anchor 70, which permits fastening and tensioning of the tissue 120 to the humerus 122 over a large area. While two anchors 30 and 70 are illustrated, any suitable number of anchors can be added to the suture tail 12, as described in the '304 Application for example, and implanted in a similar fashion to fasten a larger area of the tissue 120 to the humerus 122.

Although the tissue 120 is illustrated as one complete piece of tissue 120 in FIGS. 7A-7C, the knotless suture anchor device 10 can be used to couple, secure, and retain two separated (i.e., torn) portions of the tissue 120 together. For example and with reference to FIG. 7C, the knotless suture anchor device 10 can be arranged such that the first and the second anchors 30 and 70 are implanted on opposites of a tear in the tissue 120. Tightening the knotless suture anchor device 10 by pulling on the second end 60 as described above, will pull the two torn pieces together to facilitate healing.

With additional reference to FIGS. 8A and 8B, another method for securing the rotator cuff tissue 120 to the humerus 122 will now be described. As illustrated, bone hole 124 is formed in the humerus 122 laterally offset from an edge 136 of the tissue 120. The first portion 66 of the suture tail 12 is passed through the tissue 120 such that the first end 16 is first inserted into the inner surface 134 and then is pushed or pulled out from the outer surface 132, as illustrated in FIG. 8B. The anchor 30 is implanted in the bone hole 124 either before or after the first portion 66 of the suture tail 12 is passed through the tissue 120. After the anchor 30 is implanted, the first end 16 of the suture tail 12 is inserted through the first adjustable suture loop 50 (FIG. 8B), the suture construct 14 is pulled and carried through the anchor 30 (FIG. 8C), and the suture construct 14 is tightened to secure the tissue 120 to the humerus 122 (FIG. 8D). As illustrated in FIGS. 8C and 8D, pulling the suture construct 14 through the anchor 30 and tightening the suture construct 14 pulls and stretches the tissue 120 in the medial to lateral direction. The suture construct 14 is tightened and the tissue 120 is tensioned by pulling the second end 60 of the suture construct 14. Excess portions 88 of the suture construct 14 and excess portions 90 of the suture tail 12 can then be cut and removed.

With reference to FIG. 9 , another way in which the rotator cuff tissue 120 can be secured to the humerus 122 is illustrated. The anchor 30 is implanted in the bone hole 124 formed either under the tissue 120 or laterally offset therefrom. The first end 16 of the suture tail 12 is then passed through the tissue 120 from the inner surface 134 to the outer surface 132, and then back through the tissue 120 through the outer surface 132 and out the inner surface 134. The first end 16 is inserted through the first adjustable suture loop 50 and the suture construct 14 is pulled through the tissue 120 along the same path that that the suture tail 12 was inserted. The second end 60 of the suture construct 14 is then pulled to tension the tissue 120 and secure the tissue 120 to the humerus 122.

An additional way to secure the tissue 120 to the humerus 122 is illustrated in FIG. 10 . The configuration of FIG. 10 is similar to that of FIG. 9 , except that the suture tail 12 is passed through the tissue 120 in the opposite direction. Specifically, the first end 16 of the suture tail 12 is inserted into the tissue 120 at the outer surface 132, through the tissue 120 such that the first end 16 exits the tissue 120 at the inner surface 134, back into the tissue 120 at the inner surface 134, and out from within the tissue 120 at the outer surface 132. The first end 16 of the suture tail 12 is then inserted through the first adjustable suture loop 50 and the suture construct 14 is pulled through the tissue 120 along the path that the suture tail 12 was inserted. The suture construct 14 is tightened against the tissue 120, and the tissue 120 is tensioned against the humerus 122, by pulling the second end 60 of the suture construct 14.

FIGS. 11A-11E illustrates another way to use the knotless suture anchor device 10 to secure the tissue 120 to the humerus 122. With initial reference to FIG. 11A, the first end 16 of the suture tail 12 is first passed through the tissue 120. The first end 16 is inserted into the outer surface 132 of the tissue 120, pushed or pulled through the tissue 120, and then pulled out of the tissue 120 at the inner surface. The first anchor 30 is added to the first portion 66 of the suture tail 12 in any suitable manner, such as described in the '304 Application. The first anchor 30 is implanted in the humerus 122 in any suitable manner using any suitable insertion device, such as those described herein or in the '304 Application. FIG. 11B illustrates the first anchor 30 implanted in the humerus.

With additional reference to FIG. 11C, the first end 16 of the suture tail 12 is again inserted through the tissue 120. This time the first end 16 is inserted into the tissue 120 at the inner surface 134 and passed through the tissue 120 such that the suture tail 12 exits from the outer surface 132 of the tissue 120. With additional reference to FIG. 11D, the second anchor 70 is mounted to the first portion 66 of the suture tail 12 between the first end 16 and the tissue 120 in any suitable manner, such as described in the '304 Application. The second anchor 70 is then implanted in the humerus 122. The suture tail 12 need not be passed through the tissue 120 for the second time. Thus, the suture tail 12 can extend from the first anchor 30 directly to the second anchor 70 without passing through the tissue 120 therebetween.

After the second anchor 70 is implanted, the first end 16 of the suture tail 12 is inserted through the first adjustable suture loop 50, and the suture tail 12 is pulled entirely through both the first anchor 30 and the second anchor 70 such that the suture construct 14 connects the tissue 120 to the first and the second anchors 30 and 70. The suture construct 14 is tightened by pulling on the second end 60 of the suture construct 14, which stretches and tensions the tissue 120 laterally. To further secure the suture construct 14, the first adjustable suture loop 50 can be slid away from the second body 56 to prevent the first adjustable suture loop 50 from passing over the locking member 28. FIG. 11E illustrates the suture construct 14 in its final position with excess portions of the suture tail 12 and the second end 60 of the suture construct 14 removed.

With additional reference to FIG. 12 , the tissue 120 can be secured to the humerus 122 with more than two anchors. FIG. 12 illustrates five anchors, but any suitable number of anchors can be used. The anchors can be implanted in most any suitable arrangement. For example, anchors 30, 72, and 76 can be arranged medially and generally in alignment in the anterior to posterior direction. Anchors 70 and 74 can be arranged laterally and also aligned in the anterior to posterior direction. The second adjustable suture loop 52 can be connected to the anchors 30, 70, 72, 74, and 76 in any suitable pattern and configuration. For example, and as illustrated in FIG. 12 , the second adjustable suture loop 52 can be arranged in an overlapping configuration in which the second adjustable suture loop 52 overlaps the outer surface 132 between each of the anchors 30, 70, 72, 74, and 76. The second adjustable suture loop 52 is threaded through the tissue 120 and secured thereto in the same manner described above with respect to the other ways in which the knotless suture anchor device 10 can be used to fasten the tissue 120 to the bone 102.

With additional reference to FIGS. 13A-13D, the knotless suture anchor device 10 can be used to secure two pieces of separated tissue together without anchoring the tissue to bone. Because the tissue is not anchored to bone, the device 10 does not include an anchor, such as the first anchor 30. Therefore, FIGS. 13A-13D the knotless suture anchor device 10 does not include an anchor at all.

With initial reference to 13A, a first tissue portion 140A and a second tissue portion 140B are illustrated. The first and second tissue portions 140A and 140B are separated to define a space therebetween. The first tissue portion 140A includes an outer surface 142A and an inner surface 144A that is opposite to the outer surface 142A. Similarly, the second tissue portion 140B includes an outer surface 142B and an inner surface 144B that is opposite to the outer surface 142B.

To secure the first and the second tissue portions 140A and 140B together, the first end 16 of the suture tail 12 is inserted into the inner surface 144A of the first tissue portion 140A, passed through the first tissue portion 140A, and pulled out from within the first tissue portion 140A at the outer surface 142A. From the outer surface 142A, the first end 16 is pulled across the space between the first and the second tissue portions 140A and 140B and passed through the second tissue portion 140B. The suture tail 12 enters the second tissue portion 140B at the outer surface 142B and exits the second tissue portion 140B at the inner surface 144B. The suture tail 12 is pulled entirely through both the first and second tissue portions 140A and 140B and passed through the first adjustable suture loop 50. Passing the suture tail 12 entirely through the first and the second tissue portions 140A and 140B carries the suture construct through the first and the second tissue portions 140A and 140B and connects the suture construct 14 to the first and the second tissue portions 140A and 140B, as illustrated in FIG. 13B. The second adjustable suture loop 52 is tightened by pulling on the second end 60, which draws the first tissue portion 140A and the second tissue portion 140B together. To lock the first adjustable suture loop 50 onto the second adjustable suture loop 52, the first body 54 is pushed away from the second body 56 to close the first adjustable suture loop 50. This procedure is faster, stronger, and more readily producible than tying a knot. As illustrated in FIG. 13D, locking member 28 further secures the first adjustable suture loop 50 onto the second adjustable suture loop 52.

With additional reference to FIG. 14 , an insertion device according to the present teachings is illustrated at reference numeral 202. The insertion device 202 generally includes a handle 204 and a rod or shaft 206 that extends from the handle 204. The handle 204 includes a proximal end 208 and a distal end 210. At an end of the rod 206 opposite to the handle 204 is a tip 212.

With additional reference to FIG. 15 , the insertion device 202 includes a suture retention assembly 214. The suture retention assembly 214 generally includes an anchor 216 and a passing device 218. The anchor 216 includes a first locking tab 220A and a second locking tab 220B at opposite sides of the anchor 216. Each of the first and the second locking tabs 220A and 220B are pivotable to permit the anchor 216 to be clipped onto the handle 204 and removed from the handle 204. Between the first and the second locking tabs 220A and 220B is a passing device retention member 222, which includes a first flange 224A and a second flange 224B on opposite sides thereof. The passing device retention member 222 further defines a first recess 226A and a second recess 226B on opposite sides of the passing device retention member 222. Extending from an undersurface of the anchor 216 opposite to the passing device retention member 222 is a first projection 228A and a second projection 228B. The first and second projections 228A and 228B are substantially similar to one another and face one another. They are both flexible, and biased to be compressed inward toward one another. Together, the first and the second projections 228A and 228B define a rim 230 at a distal end thereof. As further described herein, the rim 230 is configured for the first adjustable suture loop 50 to be secured thereto.

The passing device 218 includes a first clip 232A and a second clip 232B extending from opposite sides of an elongated grip 234. Between the first clip 232A and the second clip 232B is a post 236 with a ring 238 extending therefrom. The ring 238 can be made out of any suitable material having any suitable configuration that will suitable retain the suture tail 12 within the ring 238 when passed therethrough. For example, the ring 238 can be a flexible Nitinol™ ring. As further described herein, the passing device 218 is coupled with the anchor 216 such that the post 236 is seated between the first projection 228A and the second projection 228B to extend the first and the second projections 228A and 228B outward. The passing device 218 is also positioned such that the ring 238 extends beyond the rim 230. The passing device 218 is coupled to the anchor 216 in a first position through cooperation between the first clip 232A and the first recess 226A, and between the second clip 232B and the second recess 226B. The grip 234 can be moved to a second position by pulling on the grip 234 such that the first clip 232A abuts the first flange 224A and the second clip 232B abuts the second flange 224B. In the second position, the ring 238 is retracted into the first and the second projections 238A and 238B, and the post 236 is not between the first and the second projections 228A and 228B, thereby allowing the first and the second projections 228A and 228B to return to their contracted position, which will release the first adjustable suture loop 50 from the rim 230. As described further herein, when the suture tail 12 is inserted within the ring 238 and the grip 234 is moved from the first position to the second position, the suture tail 12 is pulled through the first adjustable suture loop 50.

With continued reference to FIG. 15 , the suture retention assembly 214 is coupled to the handle 204 at recess 240, which is about equidistant between the proximal end 208 and the distal end 210. The first and the second locking tabs 220A and 220B extend over the flange 242 to couple the first and the second locking tabs 220A and 220B to the handle 204. When the suture retention assembly 214 is coupled to the handle 204, the grip 234 of the passing device 218 is seated within grip cutout 244 of the handle 204. To decouple the suture retention assembly 214 from the handle 204, the first and the second locking tabs 220A and 220B are pressed inward toward the passing device retention member 222, which causes the first and the second locking tabs 220A and 220B to disengage the flange 242.

With additional reference to FIG. 16 , connection of the knotless suture anchor device 10 to the insertion device 202 will now be described. The knotless suture anchor device 10 is mounted to the insertion device 202 such that the anchor 30 is at the tip 212 between two prongs of a forked portion 246. From the anchor 30, the first portion 66 of the suture tail 12 extends to the handle 204 and is seated under the grip 234 in the grip cutout 244. The suture construct 14 is also seated in the grip cutout underneath the grip 234. The first adjustable suture loop 50 is seated on the rim 230 such that the first and the second projections 228A and 228B extend through the first adjustable suture loop 50. The second end 60 of the suture construct 14 is also seated in the grip cutout 244 underneath the grip 234. The second end 60 extends towards the proximal end 208 of the handle 204 and at its tip can extend out from underneath the grip 234. The second end 60 can be fixedly secured to the suture retention assembly 214 to facilitate passage of the first end 16 through the first adjustable suture loop 50, as further described herein.

With additional reference to FIGS. 17A and 17B, a cross-sectional view of the suture retention assembly 214 is illustrated. FIG. 17A illustrates the suture retention assembly 214 coupled to the handle 204. The suture retention assembly 214 is in the first position and the suture tail 12 is arranged such that it extends through the ring 238. With reference to FIG. 17B, the suture retention assembly 214 is illustrated decoupled from the handle 204 and the grip 234 is pulled outward to place the suture retention assembly 214 in the second position such that the first and the second clips 232A and 232B are seated against the first flange 224A and the second flange 224B respectively. In the second position, the post 236 and ring 238 pull the suture tail 12 into the first adjustable suture loop 50. The post 236 also no longer biases the first and the second projections 228A and 228B outward, thereby allowing the first and the second projections 228A and 228B to return to their biased inward positions and facilitate release of the first adjustable suture loop 50 from the rim 230.

With reference to FIGS. 18-23 , use of the insertion device 202 to secure the tissue 104 to the bone 102 with the knotless suture anchor device 10 will now be described. The insertion device 202 can also be used to implant the knotless suture anchor device 10 to any other bone to secure any other type of tissue, such as a labrum as further described herein. The bone hole 110 can be formed in the bone 102 in any suitable manner using any suitable devices.

Exemplary methods and device for forming the bone hole 110 are described in the '962 Application, which is incorporated herein by reference.

With initial reference to FIG. 18 , with the knotless suture anchor device 10 mounted thereto, the insertion device 202 is aligned above the bone hole 110 and inserted into the bone hole 110 to implant the first anchor 30 in the inner cancellous bone layer 108 against the undersurface 112 of the outer cortical bone layer 106. With reference to FIG. 19 , after the anchor 30 is positioned in the bone 102, the suture retention assembly 214 is disconnected from the handle 204. As the suture retention assembly 214 is disconnected, the first end 16 of the suture tail 12 is released from being clamped within the grip cutout 244, as is the suture construct 14. The first adjustable suture loop 50 remains coupled to the rim 230 of the first and the second projections 228A and 228B.

As illustrated in FIG. 20 , the first portion 66 of the suture tail 12 is inserted through the ring 238 of the grip 234. The grip 234 is then moved from the first position to the second position in which the ring 238 is pulled in between the first and the second projections 228A and 228B to pull the first end 16 of the suture tail 12 into the first adjustable suture loop 50. As the post 236 of the grip 234 is pulled out from between the first and the second projections 228A and 228B, the first and the second projections 228A and 228B contract to facilitate release of the first adjustable suture loop 50 from the rim 230. As a result and as illustrated in FIG. 21 , the suture tail 12 is threaded through the first adjustable suture loop 50, which decouples from the rim 230. The suture construct 14 remains connected to the suture retention assembly 214 by way of attachment of the second end 60 of the suture construct 14 to the suture retention assembly 214.

With additional reference to FIGS. 22 and 23 , the suture tail 12 is pulled entirely through the anchor 30, thereby drawing the second adjustable suture loop 52 connected thereto into and through the internal passage 40 of the anchor 30. As a result, the suture construct 14 connects the tissue 104 to the anchor 30. Prior to tightening the second adjustable suture loop 52 to the tissue 104, the suture construct 14 can by adjusted about the tissue 102 by sliding the second adjustable suture loop 52 through the internal passage 40 of the anchor 30 because the internal passage 40 is dimensioned to permit the suture construct 14 to slide therethrough. To tighten the suture construct 14 against the tissue 104 and adjust the tension of the suture construct 14, the second end 60 of the suture construct 14 is pulled. Because the second end 60 is still secured to the suture retention assembly 214, pulling of the suture second end 60 can be facilitated by pulling on the grip 234 of the suture retention assembly. Once the suture construct 14 has been tensioned to a desired degree, excess portions 88 of the suture construct extending from the second passage portion 64 can be removed. Excess portions 90 of the suture tail 12 can be removed any time after the suture tail 12 is pulled through the anchor 30 and the first adjustable suture loop 50 is secured to the second adjustable suture loop 52.

With additional reference to FIG. 24 , the suture retention assembly 214 can be modified to replace the ring 238 with a rod 248 defining a slot 250. The slot 250 is configured to receive and retain the suture tail 12 therein. The suture retention assembly 214 as illustrated in FIG. 24 will work the same way as the suture retention assembly 214 illustrated in FIGS. 14-23 .

With additional reference to FIGS. 25-27 , an additional insertion device is illustrated at reference numeral 302. The insertion device 302 generally includes a handle 304 and a rod 306 extending from the handle 304. The handle 304 includes a proximal end 308 and a distal end 310. The rod 306 extends from the distal end 310 and terminates at a tip 312 opposite to the distal end 310. The handle 304 defines a recess 314 that extends from the distal end 310 to the proximal end 308. The recess 314 also extends to a flange 316, which protrudes from the handle 304. A cap 318 can be fastened to the flange 316.

As illustrated in FIG. 26 , extending from the cap 318 is a post 320 that defines an annular recess 322 at a distal end thereof. The post 320 is sized to be received within an aperture 324 of the handle 304. The aperture 324 is aligned with the flange 316 such that when the cap 318 is connected to the flange 316, the post extends through the aperture 324 to an opposite side of the handle 304, as illustrated in FIG. 27 . The flange 316 includes a first edge 326A and a second edge 326B that is opposite to the first edge 326A. The first and the second edges 326A and 326B are spaced apart to define a gap therebetween.

An end of the flange 316 opposite to the aperture 324 includes a first tab 328A and a second tab 328B.

The knotless suture anchor device 10 is mounted to the insertion device such that the anchor 30 is seated between forked portions 330 of the tip 312. Both the first portion 66 and the second portion 68 of the suture tail 12 extend from the anchor 30 to the handle 304 and are seated within the recess 314 of the handle 304. The first portion 66 of the suture tail 12 further extends through the aperture 324 and out of the flange 316, as illustrated in FIG. 27 . When the cap 368 is connected to the flange 316, the first portion 66 of the suture tail 12 is pinched between the cap 318 and the flange 316 to retain the first portion proximate to the first end 16 at the flange 316. With further reference to FIG. 27 , the first adjustable suture loop 50 is seated within the annular recess 322 of the post 320.

Insertion device 302 is used to implant the anchor 30 in bone in the same manner as that described above with respect to the insertion device 202. After the anchor 30 has been implanted, the cap 318 is disconnected from the flange 316 to release the first portion 66 of the suture tail 12 from being coupled to the handle 304. As the post 320 is pulled out from within the aperture 324, the first adjustable suture loop 50 will contact the handle 304 and be pushed out from within the annular recess 322, thereby detaching the suture construct from the post 320 and from the handle 304. Once detached from the handle 304, the knotless suture anchor device 10 can be freely used to secure a desired tissue to bone or two tissues together. For example, the anchor 30 can be implanted in the bone hole 110 using any suitable flexible anchor insertion device. The suture tail 12 is then threaded through the first adjustable suture loop 50 by hand, and the suture construct 14 is fastened to the desired tissue as described above in connection with FIGS. 1A through 6 .

With general reference to FIGS. 28-32 and initial reference to FIG. 28 , another insertion device according to the present teachings is illustrated at reference numeral 350. The insertion device 350 includes a handle 352 with a proximal end 354 and a distal end 356 that is opposite to the proximal end 354. A rod 358 extends from the distal end 356 of the handle 352. The rod 358 terminates opposite to the distal end 356 of the handle 352 at a tip 360. The tip 360 includes a forked portion 362 that provides a retention portion for the anchor 30, as further described herein.

The handle 352 further includes a slot 364 that extends from one side of the handle to the other. The slot 364 provides a passageway for the knotless suture anchor device 10 to extend to flange 366, as further described herein. A cap 368 is configured to be releasably connected to the flange 366, to retain the second end 60 of the suture construct 14 connected to the handle 352, as further described herein. As illustrated in FIG. 29 , the flange 366 includes a first flange edge 370A and a second flange edge 370B that is spaced apart from the first flange edge 370A to define a gap between the first and the second flange edges 370A and 370B. The flange 366 further includes a first tab 372A and a second tab 372B that are configured to cooperate with the cap 368 to secure the cap 368 to the flange 366.

The insertion device 350 further includes a pin 374. A slot 376 is defined within the pin 374. Extending from the pin 374 is a post 378. A loop 380 extends from the post 378. The pin 374 is removably connected to the handle 352 in a transverse portion 364A of the slot.

With continued reference to FIGS. 28 and 29 , arrangement of the knotless suture anchor device 10 when coupled to the insertion device 350 will now be described. The device 10 is described for exemplary purposes only as any suitable retention device can be connected to the insertion device 350. The anchor 30 is positioned at the tip 360 between forks of the forked portion 362. The first portion 66 of the suture tail 12 extends towards the handle 352 and is seated within the slot 376 of the pin 374, which is seated in the transverse portion 364A of the slot 364. The second portion 68 of the suture tail 12 extends from the anchor 30 to the slot 364 and into the slot 364. The suture construct 14 connected to the second portion 68 is arranged such that the first adjustable suture loop 50 is seated within the transverse portion 364A of the slot 364 and the second end 60 of the suture construct 14 extends up through the flange 366 and out of the flange 366. The cap 368 is coupled to the flange 366 over the suture construct 14 proximate to the second end 60 to secure the suture construct 14 to the handle 352. The pin 374 is seated in the transverse portion 364A such that the post 378 extends through the first adjustable suture loop 50 and the loop 380 is on a side of the first adjustable suture loop 50.

To further retain the knotless suture anchor device 10 to the handle 352, the insertion device 350 can also include a retention strand 390. The retention strand 390 includes a first end 392 that is coupled to knob 394 of the handle 352. From the knob 394 the retention strand 390 extends to the tip 360 of the rod 358 and overlaps the anchor 30. From the anchor 30 the retention strand 390 extends into the slot 364 and to the flange 366. The retention strand 390 extends out through the flange and terminates at a second end 396 that is opposite to the first end 392. The cap 368 is secured to the flange 366 over the retention strand 390 to secure the portion of the retention strand 390 proximate to the second end 396 to the handle 352.

With additional references to FIGS. 30-32 , operation of the insertion device 350 will now be described. After the anchor 30 has been inserted into a hole formed in bone, the first portion 66 of the suture tail 12 is removed from within the slot 376 of the pin 374. The first end 16 of the suture tail 12, which is included with the first portion 66, is then inserted or passed through the loop 380 of the pin 374. The suture tail 12 is threaded through the first adjustable suture loop 50 by withdrawing the pin 374 from within the transverse portion 364A of the slot 364 and from the handle 352 altogether, as illustrated in FIGS. 31 and 32 . To decouple the suture construct 14 from engagement with the handle 352, the cap 368 is removed. With the cap 368 removed, both the second end 396 of the retention strand 390 and the suture construct 14 can be decoupled from the handle 352 by pulling them out through the slot 364. The first end 392 of the retention strand 390 can be untied from the knob 394 or be cut proximate to the knob 394. The suture construct 14 can then be tightened as described above.

Use of the knotless suture anchor device 10 to repair torn labrum tissue 402 of a glenoid cavity 404 will now be described with reference to FIGS. 33-38 . Repair of the labrum tissue 402 is described for exemplary purposes only because the knotless suture anchor device 10 can be used to repair any suitable tissue, such as an acetabular labrum. The knotless suture anchor device 10 is described as being mounted to the insertion device 202 described above and illustrated in FIGS. 14-24 , but any suitable insertion device can be used, such as the insertion devices 302 and 350.

With initial reference to FIG. 33 , a suture passer 406 with a suture passing strand 408 mounted thereto is inserted through a first cannula 410 underneath a torn portion of the labrum tissue 402. A grasper 412 is inserted through a second cannula 414. The grasper 412 is used to grasp the passing strand 408 and pull the passing strand 408 up from under the labrum tissue 402. The passer 406 is removed and another grasper (not shown) is inserted through the first cannula 410 to grasp the passing strand 408. The passing strand 408 is then pulled up through the first cannula 410. The first cannula 410 is positioned anteroinferior and the second cannula 414 positioned anterosuperior. To drain any excess fluid, a fluid cannula 416 can be introduced into the glenoid cavity 404

Outside of the joint space, the passing strand 408 is tied to the first portion 66 of the suture tail 12, which is detached from the insertion device 202 by unclipping the suture retention assembly 214 from the handle 204, as illustrated in FIG. 19 , for example. As illustrated in FIG. 34 , the passing strand 408 is pulled out of the first cannula 410 to draw the suture tail 12 into the glenoid cavity 404 and around the labrum tissue 402. FIG. 35 illustrates the first portion 66 of the suture tail 12 looped around the labrum tissue 402.

FIG. 35 also illustrates a drill guide 420, which includes teeth 420A at a distal end thereof configured to cut bone for example, inserted through the first cannula 410. The drill guide 420 is positioned superiorly to the suture tail 12 and a drill 422 is inserted therethrough to form a bone hole 424 in the glenoid cavity 404. The rod 206 of the insertion device 202 is inserted through the first cannula 410 to implant the anchor 30 within the bone hole 424, such as illustrated in FIG. 19 with respect to the anchor 30 being implanted in bone hole 110. Tension is maintained on the suture tail 12 by the surgeon as the anchor 30 is implanted. The anchor 30 can be implanted by impaction, such as by striking the distal end 210 of the handle 204 with a hammer. After the anchor is implanted, the rod 206 can be removed out from within the first cannula 410.

The suture tail 12 is then inserted through the first adjustable suture loop 50 by inserting the first end 16 thereof through the ring 238 of the passing device 218, as illustrated in FIG. 20 . As illustrated in FIG. 21 , the passing device 218 is pulled outward from the anchor 216 to place the suture retention assembly 214 in the second position. The first adjustable suture loop 50 is thus released from cooperation with the rim 230. The suture tail 12 is then pulled through the anchor 30 to advance the suture construct 14 to the labrum tissue 402 and around the labrum tissue 402, as illustrated in FIG. 37 . The anchor 30 is underneath, and obstructed by, the labrum tissue 402 in FIG. 37 , and thus not specifically shown. The second end 60 of the suture construct 14 extends out from the second cannula 414, and can be grasped by the surgeon to tighten the suture construct 14 onto the labrum tissue 402 at a desired tension. FIG. 38 illustrates the suture construct 14 secured onto the labrum tissue 402 at its final position. Additional suture constructs 14A, 14B, and 14C can also be fastened to the labrum tissue in the same manner as described above to further secure the labrum tissue 402 to the glenoid cavity 404.

With reference to FIG. 39 , an additional insertion device according to the present teachings is illustrated at 502. The insertion device 502 generally includes a handle 504 and a rod 506. The handle 504 includes a proximal end 508 and a distal end 510 opposite to the proximal end 508. The rod 506 extends from the distal end 510. The rod 506 includes a tip 512 at a distal end thereof. The handle 504 defines a recess 514, a notch 516 at the distal end 510, and a guide 518 at the proximal end 508. The recess 514 is sized and shaped to receive a suture retention assembly or retention member 550 therein.

With additional reference to FIG. 40 , the suture retention assembly 550 includes a main body 552 and a plunger 554. The main body 552 includes a first coupling member 556A and a second coupling member 556B. The main body 552 includes a handle 558 at a proximal end thereof. The main body 552 defines a center bore 560 that extends through a length of the main body 552. The main body 552 defines an aperture 562 at a distal end, which is opposite to the handle 558. The aperture 562 provides an opening of the center bore 560. A support flange 564 extends axially outward from the main body 552 and the aperture 562. The support flange 564 defines a recess 566 therein, which is configured to receive the first adjustable suture loop 50 of the knotless suture anchor device 10, for example. The main body 552 is removably coupled to the handle 504 through cooperation between the first and second coupling members 556A and 556B, and retention ridge 568, which is defined by the handle 504 at the recess 514.

The plunger 554 generally includes a proximal end 570 and a distal end 572. The plunger 554 defines a center bore 574 that extends from the distal end 572 towards the proximal end 570. The center bore 574 can extend towards the proximal end 570 to any suitable position between the distal end 572 and the proximal end 570. At the proximal end 570 is an actuation pad 576, which can be grasped to facilitate movement of the plunger 554 relative to the main body 552. The plunger 554 is slidably received within the center bore 560 of the main body 552 and retained therein with retention clip 578, which cooperates with an interior surface of the center bore 560.

The plunger 554 includes a distal portion 580 at the distal end 572. A proximal portion 582 is spaced apart from the distal portion 580, and an intermediate portion 584 is between the distal portion 580 and the proximal portion 582. The intermediate portion 584 has a notch or section removed therefrom to make it smaller in cross-section than each of the distal portion 580 and the proximal portion 582. The distal and proximal portions 580 and 582 can have diameters of similar length, and offset radii. A distal flange 586 is defined by the distal portion 580 at an interface between the distal portion 580 and the intermediate portion 584. A proximal flange 588 is defined between the proximal portion 582 and the intermediate portion 584. The distal and proximal portions 580 and 582 can abut one another, and the intermediate portion 584 need not be included.

A support loop 600, such as a flexible Nitinol™ loop or ring, is arranged within the center bore 574 and fixedly mounted to the main body 552. As illustrated in FIG. 41 , prior to actuation of the plunger 554 the support loop 600 protrudes out from within the center bore 574 and beyond the distal end 572.

The support flange 564 is generally flexible and is flexed to an outwardly flexed position by the distal portion 580 when the distal portion 580 is positioned beneath the support flange 564, as illustrated in FIGS. 41 and 42 for example, in order to facilitate retention of the first adjustable loop 50 thereon. When the plunger 554 is actuated, the distal portion 580 is moved out from adjacent the support flange 564. Since no surface of the plunger 554 is present under the support flange 564 to maintain the support flange 564 in the outwardly flexed position, the support flange 564 is biased to flex inward. The support flange 564 freely flexes inward as illustrated in FIG. 43 to facilitate release of the first adjustable loop 50 from the support flange 564.

With continued reference to FIGS. 39 and 40 , and additional reference to FIG. 41 , coupling of a suture construct, such as the suture construct 14 of FIG. 1A, to the insertion device 502 will now be described. The suture construct 14 is arranged such that the anchor 30 is at and supported by the tip 512 of the rod 506. The suture retention assembly 550 is seated within the recess 514 and coupled to the handle 504 through cooperation between the first and second coupling members 556A and 556B and the retention ridges 568 of the handle 504. The suture tail 12 is positioned between the suture retention assembly 550 and the handle 504, and a portion of the suture tail 12 proximate to the first end 16 extends through the handle 504. The first end 16 is arranged on a side of the handle 504 opposite to the suture retention assembly 550. The suture construct 14 is arranged such that it extends over the proximal end 508 of the handle 504 and is seated within the guide 518 defined by the proximal end 508. The suture construct 14 continues to the suture retention assembly 550 where the first adjustable suture loop 50 is seated on the support flange 564 of the main body 552, and within the recess 566 defined by the support flange 564.

With additional reference to FIGS. 42 through 44 , operation of the suture retention assembly 550 will now be described. After the anchor 30 has been inserted into a bone hole, the suture retention assembly 550 is separated from the handle 504, as illustrated in FIG. 41 . Separating the suture retention assembly 550 releases the suture tail 12 from the handle 504. The first end 16 of the suture tail 12 is passed through the loop 600, as illustrated in FIG. 42 . With reference to FIG. 43 , the plunger 554 is pushed inward such that a distal end 572 thereof passes over the loop 600 to position the loop 600 within the center bore 574 of the plunger 554, thereby trapping the suture tail 12 within the center bore 574. Actuation of the plunger 554 also causes the proximal flange 588 to contact the first adjustable suture loop 50 and push the first adjustable suture loop 50 off of the support flange 564 and onto the suture tail 12. With reference to FIG. 44 , the suture tail 12 is then pulled entirely through the first adjustable loop 50 by pulling the suture retention assembly 550. The suture construct 14 can then be tightened by pulling on the second end 60 as described above and illustrated in FIG. 6 for example, in order to secure tissue 104 to bone 102, for example.

With additional reference to FIGS. 45-61 , a method for forming a knotless suture anchor device according to the present teachings will now be described. The reference numbers generally correspond to the knotless suture anchor device 10 described above and illustrated in, for example, FIGS. 1A and 1B, and any differences between the knotless suture anchor device 10 and the device formed in FIGS. 45-61 will be explained herein.

With initial reference to FIG. 45 , the second portion 68 of the suture tail 12 is illustrated. The second portion 68 includes a first end 68A and a second end 68B. Second end 18 of the suture tail 12 is at the second end 68B of the second portion 68. As illustrated in FIG. 46 , a threader, such as the threader 92 or any suitable threading device, is inserted through a first area of the second portion 68 of the suture tail 12 to define a first tail sleeve 68C. The threader 92 is also inserted through a second area to define a second tail sleeve 68D. The second tail sleeve 68D is closer to the first end 68A than the first tail sleeve 68C.

With the threader 92 extending through each of the first tail sleeve 68C and the second tail sleeve 68D, the first end 68A is inserted into the threader 92 and grasped by the threader 92. The threader 92 is then withdrawn through the second tail sleeve 68D and the first tail sleeve 68C in order to draw the first end 68A through the second tail sleeve 68D and into the first tail sleeve 68C, as illustrated in FIG. 47 . Therefore, the second portion 68 defines a loop 68E. Again, since the tail 16 is made from braided fibers, the first tail sleeve 68C and the second tail sleeve 68D are formed by a passage formed by the braided fibers that extends from the first end 66A to the second end 66B. Ends of each of the first tail sleeve 68C and the second tail sleeve 68D are formed by openings in the braided fibers.

With additional reference to FIG. 48 , the first portion 66 of the suture tail 12 includes a first end 66A that is opposite to a second end 66B. The threader 92 is inserted through the first portion 66 at or proximate to the second end 66B to define a third tail sleeve 66C in the first portion 66. The second end 68B of the second portion 68 is inserted through the threader 92, and the threader 92 is withdrawn through the third tail sleeve 66C in order to draw the second portion 68 into the third tail sleeve 66C, as illustrated in FIG. 49 .

With additional reference to FIG. 50 , the first end 66A of the first portion 66 is inserted through the loop 68E of the second portion 68, and the first end 66A is pulled, which pulls the third tail sleeve 66C over and past the first tail sleeve 68C and onto the second tail sleeve 68D, as illustrated in FIG. 51 . With additional reference to FIG. 52 , an excess area of the second portion 68 proximate to the first end 68A is cut from a remainder of the second portion 68. As illustrated in FIG. 53 , the first portion 66 and the second portion 68 are then pulled apart to strengthen the connection between the first portion 66 and the second portion 68, and thereby form the suture tail 12 of the knotless suture anchor device 10.

To make it easier for a surgeon to distinguish between the first portion 66 and the second portion 68 of the suture tail 12, the first portion 66 and the second portion 68 can be configured in any suitable manner to facilitate distinction therebetween, such as visual distinction therebetween. For example, the first portion 66 and the second portion 68 can include or consist of different colors, and/or different design patterns. The first and second portions 66 and 68 can also have different thicknesses or weights.

With additional reference to FIGS. 54-58 , a suture 14′ for forming a suture construct 14A (see FIG. 61 ) is illustrated. The suture construct 14A described below is similar to the suture construct 14 illustrated in FIGS. 1 and 1A, for example, but includes a first adjustable suture loop 50A that is formed differently from the first adjustable suture loop 50 of suture construct 14.

The suture 14′ includes a first end 58 and a second end 60, which is opposite to the first end 58. With reference to FIG. 55 , the inserter 92 is passed through the suture 14′ proximate to the first end 58 to define a first construct sleeve 14B therein. The second end 60 of the suture 14′ is then passed through the threader 92, and the threader 92 is withdrawn through the first construct sleeve 14B in order to pull the second end 60 of the suture 14′ through the first construct sleeve 14B to form the first adjustable suture loop 50A, as illustrated in FIG. 56 . With reference to FIG. 57 , the first adjustable suture loop 50A is seated over a spacer 96, and both the first end 58 and the second end 60 are pulled in order to tighten the first adjustable suture loop 50A, thereby making the first adjustable suture loop 50A smaller. With further reference to FIG. 58 , an excess portion of the first end 58 extending outward from the first adjustable suture loop 50A can be removed with any suitable cutting device.

With additional reference to FIG. 59 , after the first adjustable suture loop 50A is formed, the second end 60 is passed through the elongated passageway 22 at the suture tail sleeve portion 20, such as by using the threader 92. With reference to FIG. 60 , the second end 60 is then passed through a second construct sleeve 14C proximate to the first adjustable suture loop 50A, such as with the threader 92, to form the second adjustable suture loop 52. As illustrated in FIG. 61 , a knot 98 is formed proximate to the second end 60 to prevent the second end 60 from passing back through the second construct sleeve 14C.

An anchor, such as soft anchor 30, may be passed onto the suture tail 12. The soft anchor 30 may be arranged such that it covers both the third tail sleeve 66C of the first portion 66 and the second tail sleeve 68D of the second portion 68. As illustrated in FIG. 61 , the soft anchor 30 may be positioned such that the second end 66B of the first portion 66 extends slightly out from within the soft anchor 30 to facilitate insertion, such as when using one of the insertion tools 202, 302, 350, and 502 described herein. Having the third tail sleeve 66C positioned inside of the soft anchor 30 helps the soft anchor 30 stay open after the soft anchor 30 is set in bone. This allows passage of elongated passageway 22 through the anchor 30 at a lower load. Further, connection the first portion 66 and the second portion 68 inside the anchor 30 when provided with different colors permits color differentiation of the first and second portions 66 and 68 arthroscopically.

During a surgical procedure, after the suture construct 14A has been arranged around or though tissue (such as tissue 104 of FIG. 6 to secure the tissue 106 to bone 102) and the tail 12 has been passed through the first adjustable suture loop 50A such that the second adjustable suture loop 52 extends through the first adjustable suture loop 50A, the suture construct 14A is tensioned by pulling on the second end 60 of the suture construct 14A. Pulling on the second end 60 causes both the first adjustable suture loop 50A and the second adjustable suture loop 52 to become smaller. With respect to the first adjustable suture loop 50A, it becomes smaller as the suture 14′ is pulled further through the first construct sleeve 14A, with the second adjustable suture loop 52 extending through the first adjustable suture loop 50A to provide a counter force. The first adjustable suture loop 50A closes onto the second adjustable suture loop 52 seated therein to prevent the tail 12 from passing back through the first adjustable suture loop 50A.

Although the insertion tools 202, 302, 350, and 502 are illustrated and described above as including the anchor 30, the anchor need not be included. For example, any of the insertion tools 202, 302, 350, and 502 can be used to insert the suture tail 12 and suture construct 14 through the first tissue portion 140A and the second tissue portion 140B to merge the first and the second tissue portions 140A and 140B together, which does not involve use of the anchor 30.

As described above, the suture constructs 14 and 14A allow a first tissue to be coupled to a second tissue without the need to tie knots, which makes surgery, particularly arthroscopic procedures, easier and faster. In some instances, by eliminating the need to tie knots the suture constructs 14 and 14A may make the connection between first and second tissues more reliable. The suture tail 10 facilitates passing the suture construct through or around tissue, particularly during arthroscopic procedures. The suture tail 10 may be passed through or around the tissue before or after the anchor 30 has been implanted, which can further expedite and make arthroscopic procedures less complicated. 

What is claimed is:
 1. A suture anchor assembly, comprising: a first flexible tube anchor; a first suture extending longitudinally through a first longitudinal passage in the first flexible tube anchor to couple the first suture to the first flexible tube anchor; a first self-locking suture construct coupled to the first suture, the first self-locking suture construct comprised of a second suture with a first free end that extends longitudinally through a second longitudinal passage in the first suture to couple the first self-locking suture construct to the first suture, the first free end of the second suture additionally extending longitudinally through a third longitudinal passage in the second suture to form a first adjustable loop proximate a first end of the first self-locking suture construct, the first self-locking suture construct also including a second loop proximate a second end of the first self-locking suture construct; and a third suture extending longitudinally through the first longitudinal passage in the first flexible tube anchor to couple the third suture to the first flexible tube anchor.
 2. The suture anchor assembly of claim 1, wherein the second loop is formed by passing the second suture through itself.
 3. The suture anchor assembly of claim 2, wherein the first free end of the second suture extends through a portion of the second suture proximate a second free end of the second suture.
 4. The suture anchor assembly of claim 1 further comprising a second self-locking suture construct coupled to the third suture.
 5. The suture anchor assembly of claim 1 further comprising a second flexible tube anchor coupled to the first suture.
 6. The suture anchor assembly of claim 1, wherein the second longitudinal passage in the first suture is located proximate a second end of the first suture.
 7. A suture anchor assembly, comprising: a first anchor member; a first suture including a first end and a second end, the first suture extending through an opening in the first anchor member with the first end and the second end remaining outside the first anchor member; a first self-locking suture construct coupled to the first suture, the first self-locking suture construct comprised of a second suture with a first free end that extends longitudinally through a second longitudinal passage in the first suture to couple the first self-locking suture construct to the first suture, the second longitudinal passage located proximate the second end of the first suture, the first free end of the second suture additionally extending longitudinally through a third longitudinal passage in the second suture to form a first adjustable loop of the first self-locking suture construct, wherein, with the first suture extending through the opening in the first anchor member, the first end of the first suture can be pulled to pull the second longitudinal passage in the first suture through the opening in the first anchor member and thereby pull at least part of the first adjustable loop through the opening in the first anchor member; and a third suture extending through the opening in the first anchor member to couple the third suture to the first anchor member.
 8. The suture anchor assembly of claim 7, wherein the first anchor member comprises a flexible tube anchor.
 9. The suture anchor assembly of claim 7, wherein the first adjustable loop is located proximate a first end of the first self-locking suture construct.
 10. The suture anchor assembly of claim 9, wherein the first self-locking suture construct also includes a second loop proximate a second end of the first self-locking suture construct.
 11. The suture anchor assembly of claim 10, wherein the second loop is formed by passing the second suture through itself.
 12. The suture anchor assembly of claim 11, wherein the first free end of the second suture extends through a portion of the second suture proximate a second free end of the second suture.
 13. The suture anchor assembly of claim 7 further comprising a second self-locking suture construct coupled to the third suture.
 14. The suture anchor assembly of claim 7 further comprising a second anchor member coupled to the first suture.
 15. A suture anchor assembly, comprising: a first anchor member; a first suture including a first end and a second end, the first suture extending through an opening in the first anchor member with the first end and the second end remaining outside the first anchor member; and a first self-locking suture construct coupled to the first suture, the first self-locking suture construct comprised of a second suture with a first free end that extends longitudinally through a second longitudinal passage in the first suture to couple the first self-locking suture construct to the first suture, the second longitudinal passage located proximate the second end of the first suture, the first free end of the second suture additionally extending longitudinally through a third longitudinal passage in the second suture to form a first adjustable loop of the first self-locking suture construct, wherein, with the first suture extending through the opening in the first anchor member, the first end of the first suture can be pulled to pull the second longitudinal passage in the first suture through the opening in the first anchor member and thereby pull at least part of the first adjustable loop through the opening in the first anchor member, wherein the first anchor member comprises a suture material.
 16. A suture anchor assembly, comprising: a first anchor member; a first suture including a first end and a second end, the first suture extending through an opening in the first anchor member with the first end and the second end remaining outside the first anchor member; and a first self-locking suture construct coupled to the first suture, the first self-locking suture construct comprised of a second suture with a first free end that extends longitudinally through a second longitudinal passage in the first suture to couple the first self-locking suture construct to the first suture, the second longitudinal passage located proximate the second end of the first suture, the first free end of the second suture additionally extending longitudinally through a third longitudinal passage in the second suture to form a first adjustable loop of the first self-locking suture construct, wherein, with the first suture extending through the opening in the first anchor member, the first end of the first suture can be pulled to pull the second longitudinal passage in the first suture through the opening in the first anchor member and thereby pull at least part of the first adjustable loop through the opening in the first anchor member, wherein the first anchor member comprises a braided material. 